OfficeoftheGeneralCounsel
OGC‐S‐2016‐06‐AuthorizationToReleaseEducationRecords
Approved6.14.16
Page1of1
StandardFormApproved
bytheLoneStarCollege
OfficeoftheGeneralCounsel
AUTHORIZATION TO RELEASE EDUCATION RECORDS
Family Educational Rights and Privacy Act of 1974 as Amended (FERPA)
I, ______________________________________________, hereby voluntarily authorize officials at Lone Star
[Print Name of Student]
College (LSC) to disclose personally identifiable information from my education records.
Specifically, I authorize disclosure of the following information or category of information (Please check the box
or boxes that apply):
□ Grades/Transcripts
□ Financial Aid
□ Disciplinary
□ Scholarship and/or Honors
□ Photos
□ Academic Records
□ All College Records
□ Other (Please Specify) ______________________________________________________________
This information may be released to:
___________________________________________________________________________________________
___________________________________________________________________________________________
[Print Full Name(s) of Individual(s) To Whom LSC May Disclose Information]
for the purpose of informing:
□ Family
□ Educational Institution
□ Employer/Prospective Employer
□ Public or Media of Scholarship, Honor or Award
□ Other (Please Specify) _____________________________________________________________
This is to attest that I am the student signing this form. I understand the information may be released
orally or in the form of copies of written records, as preferred by the requester. This authorization will
remain in effect from the date it is executed until revoked by me, in writing, and delivered to
Department(s) identified above.
_____________________________________________ ___________________________
Student Signature Date Student ID Number
LSC-CyFair LSC-Kingwood LSC- Montgomery LSC- North Harris LSC- Tomball LSC- University Park
Student Services Student Services Student Services Student Services Student Services Student Services
281-290-3200 281-312-1613 936-273-7326 281-618-5481 281-351-3310 281-401-5370
Note: Modification of this Form requires approval of OGC
